Social Security doesn't have a disability listing for the condition known as fibromyalgia (Social Security's disability listings provide the approval criteria for a number of different impairments, ranging from amputations to seizure disorder), but the Social Security Administration (SSA) recently published a ruling giving guidance to disability claims examiners and administrative law judges (ALJs) on how to assess fibromyalgia cases. This ruling should help reduce the number of fibromyalgia claimants who are denied at the initial application stage but file an appeal and eventually win disability benefits. Even so, many FM patients will continue to be denied benefits. These patients shouldn't give up, but should pursue their disability claim through the appeals process, keeping in mind how the Social Security Administration (SSA) views this particular impairment (which is also known as fibromyositis).
How Does Social Security View Fibromyalgia?
Traditionally, when a disability claims examiner received a case in which the only allegation (reason for disability) was fibromyalgia, the outlook for an initial approval was poor. Disability examiners generally gave little weight to a claim of fibromyalgia unless another condition was involved, such as arthritis or degenerative disc disease. For example, if a claimant made a disability claim and the chief impairments were fibromyalgia and rheumatoid arthritis, or fibromyalgia and degenerative disc disease, the fibromyalgia allegation automatically carried more weight. This may be because fibromyalgia is seen as a logical and plausible extension to what are generally thought of as "more proven" impairments. As a result, unless a fibromyalgia diagnosis was made in conjunction with another diagnosis, especially one of a musculoskeletal nature, a disability claimant with FM had little chance of getting approved after the initial disability application.
Subjective nature of fibromyalgia. Why was this? Part of the problem has to do with the nature of fibromyalgia itself. Fibromyalgia is an impairment whose symptoms are largely subjective and whose causes are not fully understood. Though it may be a legitimate disability in and of itself, because its symptoms and speculated causes vary from one person to the next, and because the medical profession is still trying to figure out FM's causes, disability examiners were never sure how to classify such cases.
Catchall diagnosis. In fact, when a primary care physician gives a patient a fibromyalgia diagnosis without a corroborative diagnosis by a specialist, to a disability examiner it may seem that the doctor gave the patient a label for lack of a better way to diagnose a patient's pain. And, unfortunately, this was often the case in the past. Many times when family doctors were unable to find reasons for the pain their patients felt, they diagnosed "fibromyalgia" as the cause. For the past decade, disability examiners have seen this routinely in the records they review. Fortunately, this is happening less and less as doctors become more familiar with fibromyalgia. But still, as a result, a fibromyalgia diagnosis made by an orthopedist or rheumatologist will still more credible to a disability examiner and will strengthen a Social Security disability claim, in contrast to situations where the fibromyalgia diagnosis has been made by an internist or family doctor. (Also see Nolo's article on getting long-term disability benefits for fibromyalgia.)
Proving You Have a Medically Determinable Impairment
To even be considered for disability benefits, you must have an impairment that has been established by medical evidence, including objective symptoms and lab tests -- your impairment cannot be established on the basis of symptoms alone. This is called having a "medically determinable impairment." Proving this can be difficult with FM, since evidence of the illness is based on subjective reports of pain, fatigue, and "fibro fog," and the SSA must see medical signs of an impairment that could reasonably be expected to produce your symptoms.
New SSR ruling. Fortunately, in July 2012, Social Security issued a ruling explaining when fibromyalgia should be found as a medically determinable impairment (MDI). The ruling directs claims examiners and judges to rely on criteria issued by the American College of Rheumatology (ACR) to determine whether an applicant has fibromyalgia, and thus has an MDI. There are two alternatives in ACR criteria that can be used in determining whether you have fibromyalgia; either one will suffice.
The ACR requires the following for a diagnosis of fibromyalgia:
Evidence of chronic widespread pain, including pain in the back, neck, or chest
- Evidence that shows your doctor ruled out other diseases that could cause the same symptoms (the symptoms of fibromyalgia often overlap with those of lupus, hypothyroidism, and multiple sclerosis), such as lab tests and examination notes, and
- One of the following:
- Tender points sites in at least 11 of 18 tender point areas of the body, with tender points occurring on both sides of the body and both above and below the waist. A list of the tender points can be viewed in the SSA's recent ruling on fibromyalgia. In testing tender points, your doctor should apply the approximate amount of pressure needed to blanch his or her own thumbnail. Or,
- Repeated manifestations of six or more fibromyalgia symptoms, signs, or conditions that often occur with FM, particularly fatigue, non-restorative sleep, cognitive or memory problems (“fibro fog”), depression, anxiety, or irritable bowel syndrome (IBS). Other possible symptoms include headache, muscle weakness, abdominal pain, Raynaud's phenomenon, seizures, and dizziness.
What allows the SSA to consider subjective complaints to be taken as "medical signs" in the case of fibromyalgia? When a symptom is an abnormality that can be documented by clinical diagnostic techniques that have been accepted by the medical profession, such as found in the definition established by the ACR, the SSA allows this as sufficient evidence.
Assessment. The claims examiner assigned to your claim will review your medical records to see if they include evidence of the above criteria. The examiner will read your doctor's notes on your complaints of pain, fatigue, and possible cognitive difficulties. To assess the credibility of your complaints, the claims examiner (or judge, if on appeal) may ask your doctor to provide information about the extent and duration of your impairments, his or her opinion of how well you are able to function, what treatments were tried and whether they were helpful and had side effects, and how long the doctor expects your ability to function to be limited. The longer your medical record includes evidence of fibromyalgia symptoms and treatment, the better. And if your various doctors agree that you have fibromyalgia, this makes your case stronger. (For more information on how the SSA assesses subjective complaints, see our article on how the SSA views complaints of chronic pain.)
Other documentation. In addition to using your treating doctor's medical records, the SSA may request records from psychologists and physical therapists you have seen and may call your relatives, friends, and neighbors as well as past employers or teachers. If the SSA doesn't have enough information to make a decision, the agency may send you to a consultative exam. At the exam, you'll be seen by a doctor who is paid by the SSA and who will report on whether you have FM, its severity, its duration, and the ways it functionally limits you.
Change in approval rates? Now that claims examiners have guidance that FM can be a medically determinable impairment despite being based on largely subjective symptoms, they should take fibromyalgia more seriously at the initial level of consideration, so that the courts hearing disability appeals aren't forced to overturn denials of disability benefits for severe fibromyalgia. However, since the SSA's ruling is so new, it will probably take months or even years to make a difference in initial application approvals.
SSA's Evaluation After the MDI Determination
If the SSA determines that you have the medically determinable impairment of fibromyalgia, according to the ACR's criteria, Social Security's evaluation is not over; in fact, it has just begun.
Technical requirements. First, the agency will investigate whether you are doing any substantial work, whether your FM is severe (has more than a minimal effect on your ability to work), and whether your impairment will last at least 12 months.
Equaling a listing. If you pass these tests, the SSA will next consider whether your FM alone or in conjunction with other impairments can be considered equivalent to any of the disabilities listed in its Blue Book of impairments (such as rheumatoid arthritis).
RFC assessment. If your condition doesn't "equal" an impairment, the SSA will next develop a residual functional capacity (RFC) assessment for you to determine if there is any work you can do, including your past work. An RFC assessment is an evaluation of your ability to perform various exertional levels of work; for example, if you can't lift more than 10 pounds, you will be given a sedentary RFC. The SSA bases your RFC on your medical records, opinions from doctors and specialists, and statements from you and possibly your family members. In assessing your RFC, the SSA will rely on your doctor's opinion as to your abilities, like how long you can stand, sit, and walk, how much you can lift, and how well you can focus and remember instructions. These functional limitations are the key to showing the SSA why you can't work.
In addition to giving you an exertional level, the RFC assessment will include limitations that may rule out various jobs at your exertional level. For instance, say you are given a sedentary RFC, but your RFC also says you need to take frequent rest breaks. This would limit the types of sedentary jobs you can do. Similarly, if you can't use your hands for fine motor movements, this would further limit the types of sedentary jobs you can do. The SSA's recent ruling on fibromyalgia states that FM pain and fatigue can cause exertional, nonexertional, and mental limitations that rule out doing some types of jobs.
After creating your RFC, the SSA will compare it to the types of jobs available for someone with your RFC level and limitations. If your RFC rules out all jobs, even sedentary work, you would be found disabled. For more information, see our articles on how Social Security uses your RFC.
What else can someone with this condition do to help tip the scales in their favor when applying for disability? You can read our article Tips on Winning Disability With Fibromyalgia, and also, since many people with fibromyalgia also have chronic fatigue syndrome (CFS), reading our article on disability for CFS may help you with your case. Fibromyalgia is also similar to myofascial pain syndrome (MPS), although MPS doesn't usually involve specific trigger points for pain.
But most importantly, you should consider hiring a disability representative. More so than in other cases, hiring a lawyer to appeal a denial of benefits for fibromyalgia can really help your case, since disability lawyers will be familiar with the recent ruling on fibromyalgia and the latest court decisions on when disability should be granted for fibromyalgia. This knowledge helps disability attorneys find errors made by the claims examiner or judge in the disability determination and use them to your advantage. You can contact a disability lawyer for a free consultation here.
Written by: Tim Moore, former Social Security disability claims examiner